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Pharmacy Prior Authorization

Pharmacy fee for service Prior Authorization (PA)  Contacts

Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720

Mississippi Medicaid Prescribers

Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.

All providers should register at the following link to submit prior authorization requests:

Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to Change Healthcare Pharmacy PA unit.

Drug Prior Authorization Instructions

Prior Authorization Packets Updated
Brand Name Multi-Source 6/21/2019
Early Refill 6/21/2019
Enteral Nutrition 6/21/2019
EPSDT – Beneficiaries Under 21 6/28/2019
Heterozygous Familial Hypercholesterolemia (HeFH) – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) 6/21/2019
Hepatitis C Therapy 6/28/2019
Homozygous Familial Hypercholesterolemia (HoFH) – REPATHA™ (EVOLOCUMAB) 6/21/2019
Max Unit Override 6/21/2019
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 6/21/2019
Opioid Packet – Effective 8/1/2019 8/1/2019
PDL Exception Request 6/21/2019
RSV-SYNAGIS® 6/21/2019
Universal Prior Authorization Form 6/21/2019


Manual Prior Authorization Criteria

Pharmacy Reconsideration Request Form

MedWatch Form